 |
| |
VOL. 27, NO. 44, July18 , 2008 (Shrawan 03 2065 B.S.)
|
|
HEALTH GOVERNANCE
Delivery of Death!
The very act of giving birth is still the leading cause of death of women in the country. Latest Demographic and Health Survey (DHS), which is conducted every five years by the government, indicated a sharp fall in MMR from 539 in 1996 to 281 a decade later for every 100,000 live births. However, the decline is not evenly spread out across the country. Among backward communities and in rural regions, the maternal health situation is still unimproved. The same survey points to an unsettling fact: one in five of all women aged between 15-49 years who died during the survey period (2001-2006) died while giving birth or due to complications related to their pregnancies. Moreover, even among those women who survive childbirth, many suffer from chronic consequences. For every woman who dies during childbirth, there will be twenty others who suffer from debilitating consequences triggered by a host of reasons including lack of medical care, multiple pregnancies, early marriage and so on. This situation is a stark reminder of poor health governance in the country, particularly the concentration of health facilities in urban areas, which exposes a large segment of poor population to the serious health threats
By SANJAYA DHAKAL
Recently when a local social activist Prasis Mahara met Parvati Parki in Doti district of far-western region in Nepal, Parvati made a simple request – she wanted poison. Unable to bear the constant pain and discomfort due to severe uterine prolapse (also called fallen womb), Parvati had expressed her wish to die at the first opportunity she got to narrate her misery.
Wrinkled beyond her age, Parvati, 36, looks like she is a 60-year-old woman due to the hard life she has been through. She comes from a marginalised Dalit (so-called untouchables) community. She was married at the age of 10 with a man 20 years older. She gave birth to 10 children – six of whom survived. Two years ago, she gave birth to her last child but that delivery proved too much for her frail, weary and undernourished body. Her uterus gave in. She suffered from severe case of uterine prolapse, which is a debilitating condition in which the supporting pelvic structure of muscles, tissue, and ligaments gives way, and the uterus drops out of the vagina.
"She cannot work or walk normally. She has to pass urine standing up. Simple daily routines have become grueling punishment for her," Mahara said.
Doctors say that such a condition is often the result of difficult labour, frequent pregnancies, lack of antenatal care and rigorous working schedule. They say that in less severe cases, the fallen womb can be stabilised by inserting a rubber ring, or pessary while surgery is required in severe cases. "In Nepal, where fertility is high and women carry heavy loads on their backs, one out of ten women are estimated to suffer from the condition," according to United Nations Population Fund (UNFPA). The UNFPA has said that 600,000 women all over Nepal need urgent medical care for uterine prolapse.
Due to lack of money for treatment and social stigma associated with illness, Parvati had not disclosed her agony to anyone and had not visited a health center even though she lives few hours away from district administration office and health post in Dhamigaon-5 of Silgadi municipality in Doti district.
Each time she gave birth, she did that all alone and used rusty sickles to cut off the umbilical cord. Particularly, in far and mid west region of Nepal, there is a tradition whereby women have to give birth in a secluded and unhygienic shed away from her husband and other male members of family. Most of them will get the help from traditional birth attendants. Some, like Parvati, go through the suffering all alone.
Even the latest DHS shows that a whopping 81 percent of births still take place in homes and remaining take place in a health facility. Five years ago, the percentage of women delivering in a health facility was less than half. Even now seven percent of births are delivered without any type of assistance at all.
On such a backdrop, the news of a sharp decline in MMR in a period of ten years - which were marked by extreme instability, violent conflict and contraction of state's presence from various rural areas - has been received with much skepticism.
Even senior government officials have expressed 'pleasant surprise' over the dramatic fall in the MMR. "Various reasons like increased awareness, expansion of health care facilities, immunisation, antenatal care may be behind this fall. As the fall has been very substantial, we are currently engaged in further analysis to find out the truth," said Ram Hari Aryal, a former joint secretary at the Ministry of Health and Population.
Bhogendra Dotel, senior officer at Family Health Division of the Ministry, added that improvement in family planning awareness, which is evident by the increase in Contraceptive Prevalence Rate (CPR) from 39 to 48 percent in last five years, is largely responsible for the decline in MMR. "The average family size has decreased from 4.6 children (for every parent) in 1996 to 4.1 in 2001 to 3.1 in 2006. This means there have been lesser pregnancies and, by that extension, lesser deaths," he said.
He, however, conceded that CPR and family planning awareness have increased much more in urban areas than in rural areas and among backward communities.
Mahara who has been working in remote areas of Doti district – which is one of the most backward districts in Nepal in terms of human development indicators - in promoting social and health issues for the last one and a half decade, says that she has not seen dramatic improvement in MMR situation in that region. "Maybe the MMR has fallen because of improvement in urban areas. But in rural areas, the fall is not at all that dramatic," she said.
Agrees former minister who hails from Doti district, Bhakta Bahadur Balayar. "The situation not only in Doti but other backward districts is similar. The improvement is coming very slowly in rural regions. The dramatic fall in MMR is possibly because of huge improvement in urban areas," said Balayar.
Substantiating their claims, the DHS shows considerable differences in maternal health indicators for women living in different parts of the country. It shows that while 85 percent of urban women received antenatal care from Skilled Birth Attendant (SBA is a person with basic training on maternal health), only 38 percent of rural women did so.
The DHS adds that about twice as many mothers living in central, western and eastern regions (which are relatively more developed) received antenatal care from SBA as mothers living in far western region. Urban women (52 percent) are twice as likely as rural women (26 percent) to have received four or more antenatal visits. The WHO has prescribed at least four antenatal care visits.
Almost half (48 percent) of children in urban areas are born in a health facility, compared with 14 percent in rural areas. Since Nepal is known as a country of villages – there are 3913 Village Development Committees (VDCs) compared with 58 municipalities – the poor situation in rural region would drag down the overall national growth.
Wrecked by violent conflict and grinding poverty, Nepal has not been able to improve its health situation. At present, for every 18,439 people there is one doctor. Likewise, for every 2349 people, there is one hospital bed. And even these doctors and hospitals are concentrated in urban centers.
As leaders of the world have expressed their commitment to improve maternal health substantially by 2015 as a part of Millennium Development Goals (MDGs), it is imperative for Least Developed Countries (LDCs) like Nepal to redouble their efforts to bring down MMR and maternal health-related problems not only in urban but also in rural areas and among traditionally marginalised communities. Parvati and similar other women of Nepal deserve no less.
For this to happen, however, the government needs to overhaul its health governance system to make them people-oriented and expand the reach of the health professionals and health facilities to the remotest corner of the country where women like Parvati are continuing to go through immeasurable agony.
